Surgical Management of Patella Fractures
Surgery is necessary for patella fractures that have displacement greater than 2-3 mm, articular step-off greater than 2 mm, or disruption of the knee extensor mechanism. 1
Indications for Surgical vs. Non-Surgical Management
Surgical Treatment Indicated When:
- Displacement >2-3 mm
- Articular step-off >2 mm
- Disruption of the extensor mechanism
- Open fractures
- Comminuted fractures with displacement
Non-Surgical Treatment Appropriate For:
- Undisplaced fractures
- Intact extensor mechanism
- Minimal (<2 mm) articular incongruity
Imaging Assessment
Before making treatment decisions, proper imaging is essential:
- First-line imaging: AP, lateral, and patellofemoral (sunrise/Merchant) radiographic views 2
- Advanced imaging when needed:
- CT scans for complex fracture patterns, preoperative planning, and assessment of articular involvement
- MRI for suspected soft tissue injuries and osteochondral fractures
Surgical Techniques
The choice of surgical technique depends on fracture pattern:
- Modified tension band wiring: Most commonly used technique suitable for most fracture types 3
- Cannulated lag screws with tension band wiring: Preferred for horizontally displaced two-part fractures due to superior biomechanical stability 3
- Plate fixation: For comminuted fractures or when standard tension band wiring is inadequate 4
- Partial or total patellectomy: Reserved as a salvage procedure for severely comminuted fractures 3
Complications and Pitfalls
- Hardware-related issues: Pain from prominent hardware often necessitates removal after fracture healing 5
- Posttraumatic arthritis: Failure to restore articular congruity leads to patellofemoral arthritis 5
- Functional deficits: Substantial functional limitations may persist even after fracture healing 4
- Quadriceps weakness: Particularly after patellectomy procedures 3
Rehabilitation Considerations
Early rehabilitation is recommended regardless of treatment method to:
- Prevent knee stiffness
- Maintain quadriceps strength
- Restore range of motion
- Prevent falls, especially in elderly patients 5
Long-Term Outcomes
- Patellofemoral arthritis is common after patella fractures despite appropriate treatment 4
- Most patients achieve satisfactory results with appropriate surgical intervention 6
- Functional deficits may persist long after fracture healing, requiring ongoing rehabilitation 4
The decision for surgical intervention should be made promptly to restore the extensor mechanism, which is essential for unassisted gait and normal knee function. Meticulous surgical technique focusing on anatomic reduction of the articular surface is critical to minimize long-term complications and optimize functional outcomes.